By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Cigna in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Your Fastest Path to Soliris Coverage

Cigna requires prior authorization for Soliris (eculizumab) in Illinois based on FDA-approved indications with specific diagnostic testing. Submit through CoverMyMeds or provider portal with specialist evaluation, required labs (flow cytometry for PNH, anti-AChR antibodies for myasthenia gravis), meningococcal vaccination proof, and REMS enrollment. Standard review takes 72 hours; expedited 24 hours if urgent. First step today: Verify your diagnosis meets Cigna's criteria and gather vaccination records—most denials stem from missing safety documentation.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications CoverMyMeds, provider portal Cigna Policy IP_0549
Formulary Tier Specialty tier Member portal Cigna Formulary
Step Therapy Removed July 2024 No longer required Policy Updates
Meningococcal Vaccination MenACWY + MenB ≥2 weeks before Vaccination records FDA REMS
REMS Enrollment Prescriber must enroll UltSolREMS.com FDA Requirements
Age Restrictions Varies by indication ≥6 years (PNH), ≥18 years (gMG, NMOSD) Cigna Policy IP_0549

Eligibility Triage: Do You Qualify?

Likely Eligible ✅

You meet these criteria for your condition:

Paroxysmal Nocturnal Hemoglobinuria (PNH):

  • Age ≥6 years
  • Flow cytometry confirms GPI-anchored protein deficiency
  • If ≥18: LDH ≥1.5x upper normal limit AND transfusion history or major PNH symptoms
  • Completed meningococcal vaccination ≥2 weeks ago

Atypical Hemolytic Uremic Syndrome (aHUS):

  • Progressive thrombotic microangiopathy despite supportive care
  • Normal ADAMTS13 activity (ruling out TTP)
  • No Shiga toxin E. coli infection
  • Completed meningococcal vaccination ≥2 weeks ago

Generalized Myasthenia Gravis (gMG):

  • Age ≥18 years
  • Positive anti-acetylcholine receptor (AChR) antibodies
  • MGFA Class II-IV symptoms
  • Completed meningococcal vaccination ≥2 weeks ago

Neuromyelitis Optica Spectrum Disorder (NMOSD):

  • Age ≥18 years
  • Positive anti-aquaporin-4 (AQP4) antibodies
  • At least one documented relapse
  • Neurologist evaluation
  • Completed meningococcal vaccination ≥2 weeks ago

Possibly Eligible ⚠️

You need additional documentation:

  • Missing required antibody/genetic testing
  • Vaccination incomplete or undocumented
  • REMS enrollment pending
  • Recent lab values needed (≤3 months old)

Not Yet Eligible ❌

Consider these next steps:

  • Complete diagnostic testing with specialist
  • Obtain required vaccinations (allow 2+ weeks before treatment)
  • Document treatment failures if applicable
  • Prepare for formulary exception request

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Formulary Status

Who: Patient or clinic staff
What: Check if Soliris is covered under your specific Cigna plan
How: Log into Cigna member portal or call member services
Timeline: Same day

2. Gather Required Documentation

Who: Patient and specialist
What: Collect all diagnostic tests, vaccination records, and clinical notes
Documents needed:

  • Specialist evaluation ≤30 days old
  • Diagnostic confirmation (flow cytometry, antibody tests)
  • Meningococcal vaccination records (MenACWY + MenB)
  • Recent labs (LDH, hemoglobin, creatinine as applicable)
  • Treatment history if applicable

3. Complete REMS Enrollment

Who: Prescribing physician
What: Enroll at UltSolREMS.com before prescribing
Why: FDA requirement—cannot start treatment without enrollment
Timeline: Allow 1-2 business days for approval

4. Submit Prior Authorization

Who: Prescriber or clinic staff
What: Complete Cigna's Soliris PA form
How: Submit via CoverMyMeds (preferred), provider portal, or fax
Timeline: 72 hours standard, 24 hours expedited

5. Include Site of Care Information

Who: Clinic staff
What: Specify where infusions will occur (home, office, infusion center)
Why: Cigna may have site-of-care restrictions
Note: Verify current requirements with Cigna as policies change frequently

6. Request Peer-to-Peer if Complex

Who: Prescribing physician
What: Request direct conversation with Cigna medical director
When: For borderline cases or if initial review seems unfavorable
How: Call Cigna provider services to schedule

7. Track and Follow Up

Who: Patient and clinic
What: Monitor PA status and respond to requests for additional information
Timeline: Cigna must respond within stated timeframes

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Missing vaccination proof Submit complete vaccination records MenACWY and MenB vaccination cards/records
Diagnostic criteria not met Provide specialist confirmation Flow cytometry results, antibody titers, genetic testing
Site-of-care restriction Request medical necessity exception Letter explaining why specific site is medically necessary
Quantity limits exceeded Document medical necessity for dosing Clinical rationale for FDA-approved dosing schedule
"Not medically necessary" Submit comprehensive clinical evidence Specialist letter, treatment failures, guidelines citations
REMS enrollment missing Complete prescriber enrollment REMS approval confirmation from UltSolREMS.com

Appeals Playbook for Cigna in Illinois

Internal Appeals (Required First Step)

Level 1 Internal Appeal:

  • Deadline: 180 days from denial notice
  • How to file: Complete Cigna Customer Appeal Request form
  • Submit to: Cigna Appeals Unit, PO Box 188011, Chattanooga, TN 37422
  • Response time: 30 days for medical necessity decisions
  • Success rate: ~80-85% with peer-to-peer review

Level 2 Internal Appeal:

  • Deadline: 60 days after Level 1 denial
  • Process: Same form and address as Level 1
  • Response time: 30 days
  • Note: Required before external review eligibility

Illinois External Review

After exhausting Cigna's internal appeals, Illinois residents have strong external review rights:

Timeline: Must file within 4 months of final internal appeal denial (shorter than many states—act promptly)

How to file:

Review process:

  • Independent Review Organization (IRO) assigned within 1 business day
  • IRO decision within 5 business days of receiving materials
  • Expedited reviews: 72 hours for urgent cases
  • IRO decision is binding on Cigna

Cost: Free to patients—Illinois insurers pay review costs

Illinois-Specific Resources

Illinois Department of Insurance Consumer Assistance:

  • Phone: (877) 527-9431
  • Website: idoi.illinois.gov
  • Services: Help filing appeals and external reviews

Illinois Attorney General Health Care Bureau:

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist

Patient Problem Statement:

  • Specific diagnosis with ICD-10 codes
  • Disease severity and functional impact
  • Current symptoms and limitations

Prior Treatment History:

  • Previous medications tried (drug, dose, duration)
  • Reasons for discontinuation (ineffective, intolerable, contraindicated)
  • Response to supportive care measures

Clinical Rationale:

  • Why Soliris is medically necessary for this patient
  • Expected clinical outcomes and monitoring plan
  • Consequences of treatment delay

Guideline Citations: Include references to:

Monitoring Plan:

  • Laboratory monitoring schedule
  • Clinical assessment intervals
  • Safety monitoring protocols
From our advocates: We've seen that appeals including specific functional improvement goals (e.g., "reduce transfusion requirements from monthly to quarterly" for PNH) tend to be more successful than general medical necessity statements. Quantifiable outcomes help medical directors understand the clinical value.

FAQ

How long does Cigna prior authorization take in Illinois? Standard review is 72 hours; expedited review is 24 hours if you attest that standard timeline would jeopardize life, health, or function. Source: Cigna PA policies

What if Soliris is non-formulary on my plan? Request a formulary exception through Cigna's standard process. Your physician must certify that formulary alternatives are contraindicated or ineffective for your condition.

Can I request an expedited appeal in Illinois? Yes, if treatment delay would seriously jeopardize your health. Both Cigna internal appeals and Illinois external reviews have expedited pathways available.

Does the Illinois external review cost anything? No. Illinois insurers pay all costs for external reviews, and there are no fees for patients to request independent review.

What vaccination requirements apply to Soliris? FDA requires meningococcal vaccination against serogroups A, C, W, Y, and B at least 2 weeks before starting Soliris. This is due to increased meningococcal infection risk with complement inhibition.

How does Counterforce Health help with Soliris appeals? Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to payer requirements.

When patients face complex insurance denials for specialty medications like Soliris, having expert support can make the difference between coverage approval and continued treatment delays. Counterforce Health helps patients, clinicians, and specialty pharmacies navigate the prior authorization process by identifying specific denial reasons and crafting appeals with the right clinical evidence and procedural requirements for each payer.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For personalized assistance with Illinois insurance appeals, contact the Illinois Department of Insurance at (877) 527-9431.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.